Client Intake Form | Den Holistic

List your major health concerns in order of importance.

List the date and description of any surgical procedures you have had or plan to have in the future.

Do you have any allergies? If yes, please list them below:

Are you currently taking any medications? If yes, please identify the medication name and purpose

How would you describe your general health?

Please list any skin conditions you may have and briefly describe your symptoms (ex: eczema, psoriasis, dermatitis, acne, etc)

List your favorite foods / meals you like to eat:

List your least favorite foods / anything you dislike eating (including condiments)

List any foods you exclude from your diet

List any foods that you crave

Are there any foods that you avoid because of the way they make you feel? If yes, please name the food and the symptom

Have you ever had or have periods of eating junk food, binge eating or dieting? List any known diet that you have been on for any amount of time:

Please list all known food allergies, sensitivities, intolerances and/or reactions